{"id":39410,"date":"2013-10-21T08:00:49","date_gmt":"2013-10-21T12:00:49","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=voices&p=39410"},"modified":"2013-10-17T11:25:32","modified_gmt":"2013-10-17T15:25:32","slug":"refining-the-optimal-duration-of-dual-antiplatelet-therapy-after-des-implantation","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2013\/10\/21\/refining-the-optimal-duration-of-dual-antiplatelet-therapy-after-des-implantation\/","title":{"rendered":"Refining the Optimal Duration of Dual Antiplatelet Therapy After DES Implantation"},"content":{"rendered":"

CardioExchange\u2019s Harlan Krumholz<\/b> interviews Cheol Whan Lee<\/b> and Seung-Jung Park<\/b> about their study group\u2019s randomized trial comparing dual antiplatelet therapy with aspirin alone beyond 12 months after drug-eluting stent implantation. <\/i>The findings are published in <\/i>Circulation.<\/i><\/a><\/p>\n

THE STUDY<\/b><\/p>\n

At 24 centers in South Korea, 5045 patients who received a drug-eluting stent (DES) and were free of major adverse cardiovascular events and major bleeding for at least 12 months after the procedure were randomly assigned, in open-label fashion, to receive aspirin alone or to continue clopidogrel plus aspirin. Incidence of the primary endpoint \u2014 a composite of death from cardiac causes, myocardial infarction, or stroke at 24 months after randomization \u2014 was similar in the two groups (aspirin alone, 2.4%; dual therapy, 2.6% (hazard ratio, 0.94; 95% CI, 0.66\u20131.35; P<\/i>=0.75), as were the individual risks for all-cause mortality, MI, stent thrombosis, and stroke. The incidence of major bleeding was 1.1% in the aspirin-alone group and 1.4% in the dual-therapy group, (HR, 0.71; 95% CI, 0.42\u20131.20; P<\/i>=0.20).<\/p>\n

THE INTERVIEW<\/b><\/p>\n

Krumholz:<\/i><\/b> In your study, the benefit of extending dual antiplatelet therapy beyond 12 months was similar to that of aspirin alone. What is the usual practice in South Korea?<\/i><\/b><\/p>\n

Lee and Park:\u00a0<\/i><\/b>Dual antiplatelet therapy (DAPT)\u00a0for 6 to 12 months after DES implantation is usual practice in Korea. Beyond 6 to 12 months after DES implantation, most doctors discontinue DAPT and use\u00a0either aspirin or clopidogrel alone.<\/p>\n

Krumholz:<\/i><\/b> In <\/b>a previous study of yours<\/b><\/a>, you found a similar result. Why was it necessary to do this study?<\/b><\/p>\n

Lee and Park:<\/i><\/b> <\/b>As we describe in our introduction,\u00a0the long-term\u00a0dual-therapy arm in the first study was associated with a trend toward increased risk for cardiac death and myocardial infarction. We did the second study to confirm this observation.<\/p>\n

Krumholz:<\/i><\/b> Your confidence intervals are quite wide. You cannot exclude a benefit of as much as a 34% lower risk. Given that lower limit, do you feel confident that you can really exclude a benefit of longer DAPT?<\/b><\/p>\n

Lee and Park:\u00a0<\/i><\/b> <\/b>We agree. To narrow the confidence interval, we would need a much larger study. However,\u00a0this is now difficult because 6 to 12 months of DAPT is\u00a0usual practice in the era of new DES.<\/p>\n

Krumholz:<\/i><\/b> You powered the study for a 50% reduction. On what basis did you identify that as the right effect size to detect? Wouldn\u2019t people care about a smaller effect than that?<\/b><\/p>\n

Lee and Park:<\/i><\/b> <\/b>We agree. The sample size was based on the first study\u2019s findings. As you know,\u00a0this kind of study is difficult to conduct because of low patient participation and poor compliance.<\/p>\n

Krumholz:<\/i><\/b> What is the next study that should be done in this area?<\/b><\/p>\n

Lee and Park:<\/i><\/b>\u00a0<\/i>DES technology has improved greatly during the past decade.\u00a0New DES seems to be\u00a0safer than bare-metal\u00a0stents, and\u00a0stent thrombosis mostly occurs within 3 months after new DES implantation.\u00a0Therefore, we think that\u00a0the duration of DAPT can be further shortened in the era of new DES, a topic for the next study.<\/p>\n

JOIN THE DISCUSSION<\/b><\/p>\n

What effect will the trial conducted by Dr. Lee and Dr. Park have on your practice and on the direction of research on dual antiplatelet therapy after drug-eluting stent implantation?<\/b><\/b><\/p>\n","protected":false},"excerpt":{"rendered":"

Cheol Whan Lee and Seung-Jung Park discuss their study group\u2019s randomized trial comparing dual antiplatelet therapy with aspirin alone beyond 12 months after drug-eluting stent implantation.<\/p>\n","protected":false},"author":859,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[9],"tags":[364,334,821,861,301],"class_list":["post-39410","post","type-post","status-publish","format-standard","hentry","category-interventional-cardiology","tag-aspirin","tag-clopidogrel","tag-drug-eluting-stents","tag-dual-antiplatelet-therapy","tag-pci"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/39410","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/859"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=39410"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/39410\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=39410"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=39410"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=39410"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}